Health education improves referral compliance of persons with probable Diabetic Retinopathy: A randomized controlled trial

Zara Khair, Md Moshiur Rahman, Kana Kazawa, Yasmin Jahan, Abu S G Faruque, Mohammod Jobayer Chisti, Michiko Moriyama, Zara Khair, Md Moshiur Rahman, Kana Kazawa, Yasmin Jahan, Abu S G Faruque, Mohammod Jobayer Chisti, Michiko Moriyama

Abstract

Objective: Lack of awareness about Diabetic Retinopathy (DR) is the most commonly cited reason why many persons with type 2 diabetes are non-compliant with referral instruction to undergo retinal screening. The purpose of this study was to evaluate the efficacy of a culturally, geographically and socially appropriate, locally adapted five-month-long health education on referral compliance of participants.

Method: A prospective randomized, open-label parallel group study was conducted on persons with type 2 diabetes who underwent basic eye screening at a diabetes hospital between September 2017 and August 2018. Participants who were noncompliant with referral instruction to visit a hospital for advanced DR management were randomly divided into health education intervention group (n = 143) and control group (n = 156). Both groups received information regarding DR and referral instruction at the diabetes hospital. The intervention group was provided personalized education followed by telephonic reminders. The primary endpoint was 'increase in referral compliance' and the secondary endpoint was 'increase in knowledge of DR'. Multivariate logistic regression model was used to identify significant predictors of compliance to referral.

Results: A total of nine participants dropped and 290 completed the post intervention survey. The compliance rate in intervention group was found to be significantly higher than the control group (64.3% vs 28.2%; OR 4.73; 95% CI 2.87-7.79; p<0.001). Participants in the intervention group acquired better knowledge on DR (p<0.05). Apart from intervention, referral compliance rate was also found to be significantly associated with participants' self-perception of vision problem (OR 2.02; 95% CI 1.02-4.01; p = 0.045) and participants' income (OR 1.24; 95% CI 1.06-1.44; p = 0.008).

Discussion: Our results suggest that intensive health education on DR should be integrated with diabetes education as it may result in significantly improved referral compliance. Outcomes may be sustainable if interventions are institutionalized at referral point.

Trial registration: Clinical Trials.gov (Registration # NCT03658980); https://ichgcp.net/clinical-trials-registry/NCT03658980.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. CONSORT flowchart.
Fig 1. CONSORT flowchart.

References

    1. Zimmet PZ, Magliano DJ, Herman WH, Shaw JE. Diabetes: a 21st century challenge. Lancet Diabetes Endocrinol. 2014;2(1):56–64. 10.1016/S2213-8587(13)70112-8
    1. Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9(th) edition. Diabetes Res Clin Pract. 2019;157:107843 10.1016/j.diabres.2019.107843
    1. Hypertension and Type-2 Diabetes in Bangladesh: Continuum of Care Assessment and Opportunities for Action [Internet]. Washington DC: World Bank; 2019. [cited 2020 Jun 5]. Available from: .
    1. . 2020. IDF Diabetes Atlas 9Th Edition 2019 [online] Available at: <> [Accessed 5 May 2020].
    1. Nentwich MM, Ulbig MW. Diabetic retinopathy—ocular complications of diabetes mellitus. World J Diabetes. 2015;6(3):489–99. 10.4239/wjd.v6.i3.489
    1. Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. Eye Vis (Lond). 2015;2:17 10.1186/s40662-015-0026-2
    1. Akhter A, Fatema K, Ahmed SF, Afroz A, Ali L, Hussain A. Prevalence and associated risk indicators of retinopathy in a rural Bangladeshi population with and without diabetes. Ophthalmic Epidemiol. 2013. August;20(4):220–7. 10.3109/09286586.2013.809770 .
    1. Sayeed MA, Rahman AHS, Ali MH, Rahman MM, Haq JA, Banu A. Diabetic retinopathy and visual impairment in disaster prone coastal population of Bangladesh. IMC J Med Sci. 2016; 10(1): 10–17.
    1. Ibrahim OA, Foster A, Oluleye TS. Barriers to an Effective Diabetic Retinopathy Service in Ibadan, Nigeria (Sub -Saharan Africa)—a Pilot Qualitative Study. Ann Ib Postgrad Med. 2015;13(1):36–43.
    1. Porta M, Bandello F. Diabetic retinopathyA clinical update. Diabetologia. 2002;45(12):1617–34. 10.1007/s00125-002-0990-7
    1. Zwarenstein M, Shiller SK, Croxford R, Grimshaw JM, Kelsall D, Paterson JM, et al. Printed educational messages aimed at family practitioners fail to increase retinal screening among their patients with diabetes: a pragmatic cluster randomized controlled trial [ISRCTN72772651]. Implementation Science. 2014;9(1):87.
    1. Integrated Model of Care for Diabetic Retinopathy within the Health System of Bangladesh [Internet]. International Agency for Prevention of Blindness; 2019 [cited 2020 Jun 4]. Available from: .
    1. Stewart MW. Treatment of diabetic retinopathy: Recent advances and unresolved challenges. World J Diabetes. 2016;7(16):333–41. 10.4239/wjd.v7.i16.333
    1. Lewis K. Improving patient compliance with diabetic retinopathy screening and treatment. Community Eye Health. 2015;28(92):68–9. ; PMCID: PMC4944097.
    1. Piyasena MMPN, Murthy GVS, Yip JLY, Gilbert C, Zuurmond M, Peto T, et al. Systematic review on barriers and enablers for access to diabetic retinopathy screening services in different income settings. PLOS ONE. 2019;14(4):e0198979 10.1371/journal.pone.0198979
    1. van Eijk KN, Blom JW, Gussekloo J, Polak BC, Groeneveld Y. Diabetic retinopathy screening in patients with diabetes mellitus in primary care: Incentives and barriers to screening attendance. Diabetes Res Clin Pract. 2012;96(1):10–6. 10.1016/j.diabres.2011.11.003
    1. Lawrenson JG, Graham‐Rowe E, Lorencatto F, Burr J, Bunce C, Francis JJ, et al. Interventions to increase attendance for diabetic retinopathy screening. Cochrane Database of Systematic Reviews. 2018(1).
    1. Kashim RM, Newton P, Ojo O. Diabetic Retinopathy Screening: A Systematic Review on Patients' Non-Attendance. International journal of environmental research and public health. 2018;15(1):157.
    1. Rosen L, Manor O, Engelhard D, Zucker D. In defense of the randomized controlled trial for health promotion research. American journal of public health. 2006;96(7):1181–6. 10.2105/AJPH.2004.061713
    1. Walker EA, Schechter CB, Caban A, Basch CE. Telephone intervention to promote diabetic retinopathy screening among the urban poor. American journal of preventive medicine. 2008;34(3):185–91. 10.1016/j.amepre.2007.11.020
    1. Anderson RM, Musch DC, Nwankwo RB, Wolf FM, Gillard ML, Oh MS, et al. Personalized follow-up increases return rate at urban eye disease screening clinics for African Americans with diabetes: results of a randomized trial. Ethn Dis. 2003;13(1):40–6.
    1. Almalki NR, Almalki TM, Alswat K. Diabetics Retinopathy Knowledge and Awareness Assessment among the Type 2 Diabetics. Open Access Maced J Med Sci. 2018;6(3):574–7. 10.3889/oamjms.2018.121
    1. Halbert RJ, Leung KM, Nichol JM, Legorreta AP. Effect of multiple patient reminders in improving diabetic retinopathy screening. A randomized trial. Diabetes Care. 1999;22(5):752–5. 10.2337/diacare.22.5.752
    1. Mwangi N, Bascaran C, Ramke J, Kipturgo M, Kim M, Ng'ang'a M, et al. Peer-support to increase uptake of screening for diabetic retinopathy: process evaluation of the DURE cluster randomized trial. Trop Med Health. 2020;48:1 10.1186/s41182-019-0188-z
    1. IBM Corp. Released 2012. IBM SPSS Statistics for Macintosh, Version 21.0. Armonk, NY: IBM Corp.
    1. Lawrenson JG, Graham-Rowe E, Lorencatto F, Rice S, Bunce C, Francis JJ, et al. What works to increase attendance for diabetic retinopathy screening? An evidence synthesis and economic analysis. 2018;22(29):1–160.
    1. Weiss DM, Casten RJ, Leiby BE, Hark LA, Murchison AP, Johnson D, et al. Effect of Behavioral Intervention on Dilated Fundus Examination Rates in Older African American Individuals With Diabetes Mellitus: A Randomized Clinical Trial. JAMA ophthalmology. 2015;133(9):1005–12.
    1. Zhang X, Norris SL, Saadine J, Chowdhury FM, Horsley T, Kanjilal S, et al. Effectiveness of interventions to promote screening for diabetic retinopathy. Am J Prev Med. 2007;33(4):318–35.
    1. Jalilian F, Motlagh FZ, Solhi M, Gharibnavaz H. Effectiveness of self-management promotion educational program among diabetic patients based on health belief model. J Educ Health Promot. 2014;3:14.
    1. Kumar S, Preetha G. Health promotion: an effective tool for global health. Indian J Community Med. 2012;37(1):5–12.
    1. Prela CM, Smilie JG, McInerney MJ, Harwell TS, Helgerson SD. Direct mail intervention to increase retinal examination rates in Medicare beneficiaries with diabetes. American journal of medical quality: the official journal of the American College of Medical Quality. 2000;15(6):257–62.
    1. Lake AJ, Hateley-Browne JL, Rees G, Speight J. Effect of a tailored leaflet to promote diabetic retinopathy screening among young adults with type 2 diabetes: a randomised controlled trial. BMC Ophthalmology. 2020;20(1):80.
    1. Zangalli CS, Murchison AP, Hale N, Hark LA, Pizzi LT, Dai Y, et al. An Education- and Telephone-Based Intervention to Improve Follow-up to Vision Care in Patients With Diabetes: A Prospective, Single-Blinded, Randomized Trial. American Journal of Medical Quality. 2014;31(2):156–61.
    1. Ellish NJ, Royak-Schaler R, Higginbotham EJ. Tailored and targeted interventions to encourage dilated fundus examinations in older African Americans. Archives of ophthalmology (Chicago, Ill: 1960). 2011;129(12):1592–8.
    1. Moinul P, Barbosa J, Qian J, Chen ML, Mohaghegh M, Kaur H, et al. Does patient education improve compliance to routine diabetic retinopathy screening? Journal of telemedicine and telecare. 2018:1357633X18804749.
    1. Bush K, Thomas R, Raymond NT, Sankar S, Barker PJ, O’Hare JP. Cluster randomised controlled trial evaluation of a Link Worker–delivered intervention to improve uptake of diabetic retinopathy screening in a South Asian population. Diabetes and Vascular Disease Research. 2014;11(4):294–7. 10.1177/1479164114532964
    1. Basch CE, Walker EA, Howard CJ, Shamoon H, Zybert P. The effect of health education on the rate of ophthalmic examinations among African Americans with diabetes mellitus. American Journal of Public Health. 1999;89(12):1878–82.

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